Causes of painful sex (dyspareunia) simplified in one image

Up to 50% of women experience pain with sex (dyspareunia) at some point in their lives. There are a variety of causes, many of which are not considered by providers and/or patients. I’m lecturing on this subject today and came up with a slide that I think encompasses the main pain generators for dyspareunia, but is still an relatively easy (and intuitive) way to break things down.

Causes of painful sex:

Lesions/physical evidence: the conditions on the left typically have no lesions/changes that are visible with the naked eye after a complete exam, those on the right do. This should help narrow the differential diagnosis. For example, infection should cause a discharge, a lesion, or a rash.

Pain that is only provoked with touch versus spontaneous pain: conditions listed in the green boxes only cause pain with touch (e.g. sex, GYN exams, or using a tampon). The blue boxes typically have some spontaneous symptoms unrelated to touching the vulva or vagina, for example women with deeply infiltrating endometriosis would most likely have painful periods (dysmenorrhea) and dermatologic conditions (such as lichen sclerosus or lichen planus) either itch or have a burning pain.

So whether you are a student, a health provider, or patient I hope this chart helps to get your thoughts organized regarding pain with sex.

By the way, the answer for pain with sex is never, “It’s all in your head.” There is always a cause and it is your health care provider’s job to figure that out. The most disempowering thing is not not have a diagnosis, because you can’t formulate a treatment plan if you have no idea what you are treating.

You are a Kaiser doctor, it appears. I live here also (San Mateo), but am not a Kaiser member. Who might I see for vestibulitis, anterior vaginal wall tenderness, some nerve pain? Seen Stanford docs already and Weiss over my 21 years of pain. Thanks for any thoughts you have. Melissa

I am curious on your opinion of the mind body connection in relation to pelvic pain? I actually was a past patient of yours and had a full recovery from pelvic pain after getting pregnant via AI, but had some reoccurrence and was/am able to manage most of my symptoms through this although I am now post partum of three 8 and 9 pound babies, so that has changed things. Just interested in your thoughts about the relationship.